Septic thrombophlebitis of the inferior mesenteric vein associated with diverticulitis CT diagnosis
3
ELSEVIER SEPTIC THROMBOPHLEBITIS OF THE INFERIOR MESENTERIC VEIN ASSOCIATED WITH DIVERTICULITIS CT DIAGNOSIS LISA LEE, MD, YOUNG S. KANG, Mn, AND NICHOLAS ASTROMOFF, MD Septic thrombophlebitis of a mesenteric vein can oc- cur as a rare complication of diverticulitis. We report a case of septic thrombophlebitis of the inferior mesen- teric vein diagnosed with computed tomography, in a patient with sigmoid diverticulitis. KEY WORDS: Septic thrombophlebitis; Inferior mesenteric vein; Diverticulitis INTRODUCTION Septic mesenteric thrombophlebitis is a rare compli- cation of diverticulitis, with few documented cases of inferior mesenteric vein (IMV) involvement. We re- cently encountered a case of diverticulitis with septic thrombophlebitis of the IMV in which the computed tomography (CT) findings were diagnostic. CASE REPORT A previously healthy 43-year-old man presented with fever, chills, and mild abdominal pain. The patient was treated empirically with broad-spectrum antibiotics, and subsequent blood cultures grew Escherichia coli, Klebsiella pneumaniae, and Bacteroides fragilis. From the Santa Clara Valley Medical Center, Department of Di- agnostic Radiology, San Jose, California. Address reprint requests to: Young S. Kang, MD, Santa Clara Valley Medical Center, Department of Diagnostic Radiology, 751 S. Bascom Avenue, San Jose, CA 95128. Received July 1, 1994; accepted July 29, 1994. Initial abdominal plain films and a limited abdomi- nal ultrasound were unremarkable. Abdominal and pelvic CT, with oral and intravenous administration of contrast material, showed focal inflammatory changes in the sigmoid colon compatible with diverticulitis. To exclude an underlying neoplasm, flexible sigmoid- oscopy was performed to 35 cm, at which point there was marked edema involving the colonic folds and diverticula, with severe narrowing of the lumen, con- sistent with diverticulitis. The patient's condition deteriorated, with a temper- ature of 103.0°F and increasing abdominal pain with rebound. A second abdominal and pelvic CT, per- formed 8 days after the first scan, demonstrated con- tinued inflammatory changes in the sigmoid colon (Figure 1). A column of air was seen in what could be identified as a slightly dilated IMV (Figure 2A). Mini- mal wall thickening of the IMV, as well as soft-tissue stranding surrounding the IMV, were noted (Figure 2B). Low-density material filling the portion of the IMV near its insertion at the splenic vein was consistent with thrombus (Figure 2C). Air was visualized within the thrombus formation. These changes were consistent with thrombophlebitis of the IMV with intraluminal air. No air or thrombus was seen in the splenic or por- tal veins. As the patient was not responding to antibiotic ther- apy, exploratory laparotomy was performed. A meso- colic abscess and sigmoid diverticulitis with stricture were found. An IMV filled with clot and pus was iden- tified at surgery and confirmed on pathology After un- dergoing abscess drainage, sigmoid colectomy, divert- ing ileostomy, and Hartmann procedure, the patient recovered uneventfully. (;IAN1CAL IMAGING 1996;20:115 117 ~:, Elsevier Science Inc.. 1996 655 Avenue of the Americas, New York. NY 10010 0899-7(171/96/$15.90 SSDI 9899-7071(94)00082-N
Transcript of Septic thrombophlebitis of the inferior mesenteric vein associated with diverticulitis CT diagnosis
ELSEVIER
SEPTIC T H R O M B O P H L E B I T I S OF THE INFERIOR
MESENTERIC VEIN ASSOCIATED WITH DIVERTICULITIS
CT DIAGNOSIS
LISA LEE, MD, YOUNG S. KANG, Mn, AND NICHOLAS ASTROMOFF, MD
Septic thrombophlebitis of a mesenteric vein can oc- cur as a rare complication of diverticulitis. We report a case of septic thrombophlebitis of the inferior mesen- teric vein diagnosed with computed tomography, in a patient with sigmoid diverticulitis.
KEY WORDS:
Septic thrombophlebitis; Inferior mesenteric vein; Diverticulitis
INTRODUCTION
Septic mesenteric thrombophlebitis is a rare compli- cation of diverticulitis, with few documented cases of inferior mesenteric vein (IMV) involvement. We re- cently encountered a case of diverticulitis with septic thrombophlebitis of the IMV in which the computed tomography (CT) findings were diagnostic.
CASE REPORT
A previously healthy 43-year-old man presented with fever, chills, and mild abdominal pain. The patient was treated empirically with broad-spectrum antibiotics, and subsequent blood cultures grew Escherichia coli, Klebsiella pneumaniae, and Bacteroides fragilis.
From the Santa Clara Valley Medical Center, Department of Di- agnostic Radiology, San Jose, California.
Address reprint requests to: Young S. Kang, MD, Santa Clara Valley Medical Center, Department of Diagnostic Radiology, 751 S. Bascom Avenue, San Jose, CA 95128.
Received July 1, 1994; accepted July 29, 1994.
Initial abdominal plain films and a limited abdomi- nal ultrasound were unremarkable. Abdominal and pelvic CT, with oral and intravenous administration of contrast material, showed focal inflammatory changes in the sigmoid colon compatible with diverticulitis. To exclude an underlying neoplasm, flexible sigmoid- oscopy was performed to 35 cm, at which point there was marked edema involving the colonic folds and diverticula, with severe narrowing of the lumen, con- sistent with diverticulitis.
The patient's condition deteriorated, with a temper- ature of 103.0°F and increasing abdominal pain with rebound. A second abdominal and pelvic CT, per- formed 8 days after the first scan, demonstrated con- tinued inflammatory changes in the sigmoid colon (Figure 1). A column of air was seen in what could be identified as a slightly dilated IMV (Figure 2A). Mini- mal wall thickening of the IMV, as well as soft-tissue stranding surrounding the IMV, were noted (Figure 2B). Low-density material filling the portion of the IMV near its insertion at the splenic vein was consistent with thrombus (Figure 2C). Air was visualized within the thrombus formation. These changes were consistent with thrombophlebitis of the IMV with intraluminal air. No air or thrombus was seen in the splenic or por- tal veins.
As the patient was not responding to antibiotic ther- apy, exploratory laparotomy was performed. A meso- colic abscess and sigmoid diverticulitis with stricture were found. An IMV filled with clot and pus was iden- tified at surgery and confirmed on pathology After un- dergoing abscess drainage, sigmoid colectomy, divert- ing ileostomy, and Hartmann procedure, the patient recovered uneventfully.
(;IAN1CAL IMAGING 1996;20:115 117 ~:, Elsevier Science Inc.. 1996 655 Avenue of the Americas, New York. NY 10010
0899-7(171/96/$15.90 SSDI 9899-7071(94)00082-N
116 LEE ET AL. CLINICAL IMAGING VOL. 20, NO. 2
FIGURE 1. Inflammatory changes in the sigmoid colon (ar- row) consistent with diverticulitis.
A
DISCUSSION
Mesenteric venous thrombosis is a well-known clini- cal entity predisposed by stasis, abdominal inflamma- tion and neoplasm, hypercoagulability, as well as "pri- mary or idiopathic mesenteric venous thrombosis" which likely represents undetected hypercoagulable states. Inflammation secondary to intraabdominal in- fection historically resulted from appendicitis, Mesen- teric venous thrombosis is also described as a compli- cation of other inflammatory states, notably perforated viscus with peritonitis, sepsis associated with abdomi- nal trauma or surgery, inflammatory bowel disease, and abscess. Mesenteric thrombosis secondary to divertic- ulitis occurs in very limited clinical situations. Portal vein thrombosis sometimes with hepatic abscess and hepatic septic emboli, and gonadal vein thrombosis (1) are reported thrombotic complications of divertic- ulitis. Furthermore, there are only four reported cases of isolated IMV thrombosis, associated with antithrom- bin III deficiency (2), diverticulitis (3), and idiopathic conditions (4, 5).
The radiographic findings of portal vein and splenic vein thrombosis have been well described, principally with ultrasound, CT, and angiography. The demonstra- tion of IMV thrombosis is much less established, with angiography the most widely documented.
The value of the plain abdominal film in mesenteric venous thrombosis, commonly the initial study per- formed, is in nonspecific abnormalities, such as ileus or thickening of the bowel wall. Rarely, gas is seen in the bowel wall or portal system and is a late sign as- sociated most commonly with intestinal ischemia, but also with a variety of other conditions. Edematous bowel wall may be better seen on contrast studies of the small bowel and colon. Interestingly, a colovenous
FIGURE 2. (A) Air in the dilated inferior mesenteric vein (IMV) (arrow) with surrounding inflammatory changes. (13) At the level of the renal pelves, air and thrombus are seen in the IMV (arrow). (C) Thrombus in the IMV (arrow) at the junction of the 1MV and splenic vein.
APRIL-JUNE 1996 CT DIAGNOSIS OF MESENTERIC THROMHBOPHLEBITIS 117
fistula was demonstrated with water-soluble contrast enema in a patient with diverticulitis complicated by IMV thrombosis (3). Persistent contrast material in the IMV on the postevacuation film was noted, presum- ably because thrombus formation prevented drainage of contrast material into the portal vein.
Selective angiography in reported cases (5) showed in- tense spasm of the arteries to the affected bowel, with slow or absent blood flow. There is characteristically prolonged opacification of blood flow to the transition zone, heavy contrast staining of the mucosa, and ab- sent venous runoff from the involved bowel segment. Intraluminal filling defects of the IMV can be demon- strated during the venous phase.
The CT appearance of septic thrombophlebitis of the IMV has not been reported previously. In our patient, an air column as well as thrombus were seen in the lumen of the IMV, with inflammatory changes sur- rounding and within the wall of the vein. This cou- pled with evidence of diverticulitis on CT led to the correct preoperative diagnosis. Charnsangavej et al. (6) recently noted a case of diverticulitis with multiple ab- scess formation and air surrounding the celiac axis and inferior mesenteric vessels on CT, as a nice illustration of disease process spreading along the mesocolon. Our case illustrates the value of CT in directly demonstrat-
ing evidence of inflammatory changes within and sur- rounding the IMV. Abnormalities of the IMV itself can direct one to more careful examination of the organs in the region of drainage, leading to identification of the primary pathology. As CT is often obtained in patients with suspected infectious or inflammatory pathology in the abdomen, such as diverticulitis, one should be aware of concomitant findings involving the IMV.
REFERENCES
1. Jain KA, Jeffrey RB Jr. Gonadal vein thrombosis in patients with acute gastrointestinal inflammation: diagnosis with CT. Radiol- ogy 1991;180:111-113.
2. Manotti C, Quintavalla R, Megha A, Ponari O, Dettori AG. In- herited deficiency of antithrombin III in two Italian families. Hae- mostasis 1982;12:300-308.
3. Rothman BJ, Cloogman H, Wong D. Colovenous fistula complicat- ing diverticulitis. Am J Gastroenterol 1981;75:464-468.
4. Archibald RB, Burnstein AV, Knackstedt VE, Tolman KG, Hol- brook JH. Ischemic colitis in a young adult due to inferior mesen- teric vein thrombosis. Endoscopy 1980;12:140-143.
5. Rankin RS, Hussey JL. Idiopathic inferior mesenteric venous thrombosis demonstrated by angiography. Gastrointest Radiol 1976;1:275-276.
6. Charnsangavej C, Dubrow RA, Varma DG, Herron DH, Robinson TJ, Whitley NO. CT of the mesocolon. Radiographics 1993;13: 1309-1322.
